Healthcare Provider Details

I. General information

NPI: 1083674469
Provider Name (Legal Business Name): GRACIELA WILCOX M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST STE 360
SAN DIEGO CA
92123-2776
US

IV. Provider business mailing address

2 UPPER RAGSDALE DR STE B210
MONTEREY CA
93940-7851
US

V. Phone/Fax

Practice location:
  • Phone: 858-246-0053
  • Fax:
Mailing address:
  • Phone: 831-333-0999
  • Fax: 831-333-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31480
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number31480
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License NumberC140630
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: